Research Article
Folia Phoniatr Logop 2019;71:216–227 Published online: July 3, 2019
DOI: 10.1159/000499426
A Psycholinguistic Framework for
Diagnosis and Treatment Planning of
Developmental Speech Disorders
Hayo Terband a Ben Maassen b Edwin Maas c
a Utrecht Institute of Linguistics-OTS, Utrecht University, Utrecht, The Netherlands; b Centre for Language
and Cognition (CLCG) and University Medical Centre, University of Groningen, Groningen, The Netherlands;
c Department of Communication Sciences and Disorders, Temple University, Philadelphia, PA, USA
Keywords
Speech development · Speech disorders · Differential
diagnosis · Treatment planning
Abstract
Background: Differential diagnosis and treatment planning
of developmental speech disorders (DSD) remains a major
challenge in paediatric speech-language pathology. Differ-
ent classification systems exist, in which subtypes are differ-
entiated based on their theoretical cause and in which the
definitions generally refer to speech production processes.
Accordingly, various intervention methods have been devel-
oped aiming at different parts of the speech production pro-
cess. Diagnostic classification in these systems, however, is
primarily based on a description of behavioural speech
symptoms rather than on underlying deficits. Purpose: In
this paper, we present a process-oriented approach to diag-
nosis and treatment planning of DSD. Our framework com-
prises two general diagnostic categories: developmental de-
lay and developmental disorder. Within these categories,
treatment goals/targets and treatment methods are formu-
lated at the level of processes and rules/representations.
Conclusion: A process-oriented approach to diagnosis and
© 2019 The Author(s)
Published by S. Karger AG, Basel
E-Mail karger@karger.com This article is licensed under the Creative Commons Attribution-
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treatment planning holds important advantages, offering
direct leads for treatment aimed at the underlying impair-
ment, tailored to the specific needs of the individual and ad-
justed to the developmental trajectory.
© 2019 The Author(s)
Published by S. Karger AG, Basel
Introduction
Speech constitutes the primary channel of human so-
cial interaction; yet speaking can be considered the most
complex skill humans perform. Although most children
acquire speech relatively automatically and with little dif-
ficulty, some children struggle with the acquisition of
speech production skills and require sustained and inten-
sive treatment [1]. Children with speech disorders are at
increased risk of social-emotional and behavioural prob-
lems [2, 3], as well as of delayed development of language,
literacy, and other academic skills [4]. These issues may
limit employment and occupational opportunities in
adulthood [5, 6]. Accurate diagnostic methods and effec-
tive intervention programmes are thus of crucial impor-
tance to limit the short- and long-term impact of devel-
opmental speech disorders (DSD) on the individual.
Hayo Terband
Utrecht Institute of Linguistics-OTS, Utrecht University
Trans 10, Room 1.24
NL–3512 JK Utrecht (The Netherlands)
E-Mail h.r.terband @ uu.nl
 Unfortunately, differential diagnosis and treatment
planning of paediatric speech disorders remains prob-
lematic. Existing systems of diagnostic classification
comprise a set of theoretically grounded categories (defi-
nitions) that are associated with a symptom complex and
start from the assumption that the categories can be dif-
ferentiated by a diagnostic marker. A number of different
systems for the classification of paediatric speech disor-
ders have been proposed throughout the years [for an
overview, see 7], in which subtypes are differentiated
based on their distal or proximal cause. The predominant
systems at the moment are Shriberg’s Speech Disorders
Classification System (SDCS) [8, 9] and Dodd’s Model of
Differential Diagnosis (MDD) [10, 11]. The SDCS is a
classification based on the presumed aetiological back-
ground of the speech impairment and consists in its most
recent form of three main categories divided into eight
subcategories:
• Speech delay (SD; distal causes)
• Genetic
• Otitis media
• Psychosocial
• Motor speech disorders (MSD; proximal causes)
• Apraxia (childhood apraxia of speech; CAS)
• Dysarthria (developmental dysarthria; DD)
• Not otherwise specified (MSD-NOS)
• Residual speech errors
• /s/
• /r/
The basic idea behind the SDCS is that there are identifi-
able causes and that there are one-to-one relationships to
specific speech symptoms [9]. A fundamental problem of
the SDCS is that the classification system is inconsistent
in specifying the levels of explanation across categories.
In principle, the categorisation is based on the presumed
aetiological background [8, 9], but the two subcategories
of residual speech errors are purely symptomatic descrip-
tions at the behavioural level. Additionally and more im-
portantly, the other subcategories of SD and MSD repre-
sent factors on different levels of explanation, i.e., genetic,
otological, neurological, and psychological. Multiple fac-
tors and multiple levels could be involved in a single case,
and their exact role and weight in causing the speech
symptoms remains unclear. Moreover, the clinical char-
acterisations of the diagnostic categories consist of a ter-
minology that refers to speech production processes, but
how the aetiology is related to the processing deficit is not
specified. Thus, the SDCS can be characterised as a hybrid
classification system that has the ambition to encompass
all speech sound disorders. In its current state, however,
Process-Oriented Diagnosis of DSD
the complexity of this system due to the different levels of
causation involved, and the underspecification of the re-
lation between levels, form serious obstacles to clinical
use.
The MDD [10, 11] is based on Stackhouse and Wells’
[12] Psycholinguistic Framework, a modular psycholin-
guistic model of speech production and development.
The categorisation consists of (sub)groups that are based
on the psycholinguistic level of the presumed core deficit,
the processing level that would be affected:
• Phonological disorder (PD; phonemic level)
• Phonological delay
• Consistent
• Inconsistent
• Phonetic articulation disorder (PAD; phonetic level)
• Developmental apraxia of speech (DAS; motor level;
planning and programming)
In contrast to the SDCS, the MDD thus revolves around
the proximal cause of the different disorders (the process-
ing level) and it does not make claims about their possible
more distal causes (neurobiology or aetiology). Although
this system is consistent in terms of definitions and level
of description (the psycholinguistic level of processing),
this is only the case for the main categories, whereas sub-
categories of PD are defined based on symptomatology.
Apart from these specific issues, both classification
systems suffer the same problem in that the relation be-
tween different levels of causation, in particular the psy-
cholinguistic and the behavioural level, remains under-
specified. Diagnostic markers that are both specific and
sensitive have not yet been identified for all categories
that are differentiated (e.g., PD, CAS/DAS, and MSD-
NOS). Regardless of the theoretical basis, the definitions
of the disorders in these systems refer to speech produc-
tion processes. A variety of intervention methods for
helping children with DSD have been developed, aiming
at different parts of the speech production process, such
as lemma selection, sequencing speech sounds and sylla-
bles, and planning/programming and execution of artic-
ulatory movements. Clear criteria for determining which
treatment is the most suitable for an individual child,
however, are lacking. Thus, whereas the definitions of the
different disorders tend to refer to (hypothesised) under-
lying deficits or causes, the clinical procedures for differ-
ential diagnosis are not aimed at these definitions [see
also, e.g., 13–17, where similar conclusions were present-
ed with respect to the taxonomy of adult dysarthria]. The
current diagnostic instruments consist of tests that mea-
sure knowledge and complex skills, such as sentence for-
mulation, vocabulary, picture and colour naming, and
Folia Phoniatr Logop 2019;71:216–227 217
DOI: 10.1159/000499426
phoneme inventory. Classification comprises the assign-
ment of a diagnostic category based on a behavioural de-
scription and symptomatology. This classification proce-
dure does not provide sufficient direct information about
the underlying processes and does not allow specification
of the gradual involvement of different speech produc-
tion processes.
At the genetic level, a variety of abnormalities have
been linked with developmental speech and language dis-
orders (e.g., mutation of FOXP2 [18, 19], mutation of
GRIN2A [20], and microdeletion of BCL11A [21]). Al-
though the progress in this area is promising, the associ-
ated symptomatology is highly heterogeneous and often
encompasses speech and non-speech motor functions,
expressive and receptive language functions, and cogni-
tive functions such as short-term memory and sequenc-
ing more in general [18, 22–26]. Direct links between
genotype and phenotype have yet to be established [25,
26]. Also at the neurobiological level, few specific under-
lying deficits have been established for speech disorders
other than perhaps those affecting peripheral sensory and
motor systems. The link between particular neurobiolog-
ical findings (e.g., atypical development of the left corti-
cobulbar tract [27] and a thinner corpus callosum [28])
and cognitive and sensorimotor processes and behav-
ioural performance remains to be explicated. Further-
more, in typical clinical settings, such information about
the underlying genetic or neurobiological pathology is
rarely available. Thus, although research on the genetic
and neurobiological underpinnings of DSD may hold
promise for our understanding and, in the long term, for
clinical purposes, at present such research does not pro-
vide insights or specific suggestions to speech-language
pathologists for diagnosis or for treatment planning for
speech therapy [29]. In contrast, a focus on the underly-
ing psycholinguistic processes has clear implications for
diagnosis and treatment, as we outline further below.
The fundamental diagnostic problem is that different
levels of causation in interaction underlie the speech dis-
order, and that at none of these levels in isolation, spe-
cific and sensitive diagnostic markers for diagnostic clas-
sification can be found. Due to the interactions between
levels, there is a large overlap of symptomatology between
categories and a large heterogeneity within categories.
According to the 2004 model of Bishop and Snowling
[30], four levels of causation, or four levels of aggregation,
can be distinguished that are involved in developmental
disorders. The first, aetiological level concerns the genet-
ic constitution of the individual and environmental fac-
tors, which together determine the unfolding of the neu-
218 Folia Phoniatr Logop 2019;71:216–227
DOI: 10.1159/000499426
rological architecture at the second, neurobiological level.
The brain does not develop according to an exact prede-
termined blueprint, but is continuously adapting to bio-
logical and behavioural (environmental) circumstances.
An example would be the communicative activity level of
an infant. More active infants tend to elicit more commu-
nicative responses from the carer than do more passive
infants. The third level is the cognitive and sensorimotor,
or psycholinguistic, level describing the processes that
underlie the fourth, behavioural level.
As we have argued before, core impairments at differ-
ent levels of speech development and in different parts of
the speech production chain cannot be clearly distin-
guished from each other at the behavioural symptom lev-
el alone, but they need an understanding of the complex
interactions between causation levels [31–34]. Many ex-
amples have shown that different disorders may show
similar symptoms [17, 35], but computer simulations
have also exemplified that a specific underlying deficit
can produce symptoms on (apparently) different levels or
domains [36]. Thus, behavioural symptoms are often
multi-interpretable at the cognitive and neurobiological
level. For example, specific phoneme substitution errors
(behavioural) can often be analysed in phonological
terms as feature substitutions or in speech-motor terms
as articulatory simplifications or as sequencing errors (all
three cognitive). Likewise, specific deficits at the neuro-
biological or cognitive level, if they can be determined at
all, can result in a variety of behavioural symptoms. Thus,
diagnostic classification requires assessments at different
levels of causation and some description of the interac-
tion between levels.
A good example of this basic challenge is the history of
the dispute on the core definitions of CAS/DAS. The
comprehensive 2007 ASHA Technical Report [37] noted
that “[w]hereas some of the definitions of CAS reviewed
by the Committee view the core problem as one of plan-
ning and programming (cognitive level) the spatiotem-
poral properties of movement sequences (behavioural
level) underlying speech sound production, others pro-
pose that the deficit extends to representational-level
(cognitive) segmental and/or suprasegmental units in
both input processing and production” (p. 4). The ASHA
Technical Report has had the effect of enhancing consen-
sus on its definition of CAS as a “core impairment in plan-
ning and/or programming spatiotemporal parameters of
movement sequences” (pp. 3–4) and, currently, research-
ers seem to have agreed on this description of processes
or proximal causes underlying CAS. Thus, the report
clearly makes a choice here at the cognitive and senso-
Terband/Maassen/Maas
rimotor level. The basic problem is how to develop test
procedures such that processing and representational Conceptualisation

deficits can be distinguished. Note that all test procedures Preverbal massage Parsed speech
make use of behavioural measures, not only assessment
of symptoms, but also cognitive tests. The latter are based
Grammatical Grammatical
on behavioural assessments under strict experimental encoding decoding
and test administration procedures; also functional brain
Lemma
imaging tests make use of presenting the subject with a
Surface structure Lexicon
task to elicit behaviour such that brain activity can be in-
emexel lexeme
terpreted.
The high variability and broad spectrum of symptoms Phonological Phonological
encoding decoding
in DSD form a major challenge for clinical management
and research. Effective differential diagnosis therefore re-
quires a theoretically grounded process-oriented ap- Motor planning Internal
self-monitoring
proach focusing on clearly defined underlying deficits
Audiotory
(whether cause or processes) rather than classification Motor Feedback processing
programming
based on symptoms. Instead of searching for homoge- and memory
Somatosensory
neous groupings of overt speech symptoms and subse- processing
quently trying to identify a common cause (whether Motor execution
proximal or distal) one should start with what can be External self-monitoring
clearly defined. Although the symptomatology and aeti- Overt speech
ology are not completely clear, there is a solid theoretical
basis that allows us to precisely describe specific core
Fig. 1. Adult model of speech processing [33, 34] (adapted from
problems in terms of psycholinguistic processes [33, 34]. Levelt [39, 51], Van der Merwe [40, 50], and Guenther [45, 53]),
To identify underlying deficits, one must thus start with displaying the sensorimotor and memory functions involved in
a model of the cognitive and sensorimotor operations in- speech production and perception.
volved, from which specific hypotheses of speech symp-
toms are derived [33, 34] [see also 12, 38]. A focus on
processes instead of cause (aetiology) has the advantage different models show important similarities and overlap
that it provides direct information for treatment. In this [see also, e.g., 31, 33, 34, 38, 47].
paper, we present a theoretically based framework for Similar to any model of complex motor performance,
process-oriented diagnosis and treatment planning of all models of speech processing first and foremost adopt
DSD. a cascade-style hierarchy of control in which the output
of one process forms the input of the next processing lev-
el [e.g., 39–46, 48–52]. Leaving out all the details of dis-
An Integrated Psycholinguistic Model of Speech pute and differences in scope between models, speech
Processing production is preceded by a language process of sentence
formulation, in which lemmata are retrieved from the
The starting point of our framework is an integrated lexicon and inflected and sequenced in a grammatical
model of the cognitive and sensorimotor functions in- phrase to match intended concepts, and stored in a short-
volved in speech production and perception (Fig. 1). A term memory buffer (grammatical encoding) [e.g., 39,
variety of models of speech processing have been present- 51]. Speech production models then start with the word
ed over the years [e.g., 39–46]. Each model has its own forms (lexemes) retrieved from the lexicon, which forms
specific approach, scope and theoretical basis and the sci- the input for phonological encoding, in which the senso-
entific discussion on which model gives the best account rimotor targets that constitute the speech sounds or syl-
of all the different speech phenomena traditionally re- lables are selected and sequenced in a phonological phrase
volves around the differences between models. Whereas of linguistic/symbolic units, and stored in a short-term
the scientific endeavour tends to focus on what we do not memory buffer [e.g., 39–41, 49–51].
know, what we do know is far more important for clinical The next stage, motor planning, comprises the selec-
practice. From this perspective, it can be noted that the tion and sequencing of the articulatory movement goals

Process-Oriented Diagnosis of DSD Folia Phoniatr Logop 2019;71:216–227 219

DOI: 10.1159/000499426
that would produce these targets [e.g., 40–42, 48, 50], and
the adaptation of these goals to the phonetic environment
(e.g., coarticulation) [40, 50]. During the subsequent
stage, motor programming, the motor plans are then im-
plemented in muscle-specific motor programmes [e.g.,
40, 43, 45, 48, 50, 53], taking into account articulatory
context, sensory information, and (meta)linguistic re-
quirements (e.g., speech rate, prosody, and prominence)
[40, 50]. Finally, the constructed neural signals that con-
stitute the motor programmes are sent to the peripheral
systems and executed, resulting in the actual movements
of the articulators (motor execution) [e.g., 40, 43, 45, 48,
50, 53].
During speaking, these stages form an ongoing process
that is monitored continuously at several levels. This self-
monitoring is based on both internal and external feed-
back (Fig.  1). Internal feedback is used during motor
planning to avoid, for example, that erroneously planned
speech movements are executed [e.g., 39, 51, 54]. External
feedback comprises both fast somatosensory and slow au-
ditory monitoring and provides current information
about the state and position of the articulatory organs
(such as position, movement direction, and speed) as in-
put for motor programming [e.g., 40, 43–45, 50, 53]. Ex-
ternal feedback is further used to monitor the produced
speech on the motor programming, phonological, and
higher linguistic levels [e.g., 26, 27, 38, 41] and can be
used for ongoing adaptation of articulation and error cor-
rection [e.g., 43–45, 53].
The adult speech production system is very robust.
The different processes and representations are highly
overlearned and the system is highly redundant. In case
of acquired deafness, for example, speakers continue to
be intelligible despite the fact that auditory self-monitor-
ing is completely disabled. The situation is different, how-
ever, during speech acquisition in infants and children.
The different cognitive and sensorimotor functions are
not pre-specified in the infant brain, but they develop
gradually into the adult system [55–57]. The different
functions and representations develop simultaneously
and influence each other during development [e.g., 36,
58].
However, also in the adult speech production and per-
ception system, the different parts of the processing chain
are not fully independent. The mutual dependence be-
tween processes mainly expresses itself in the case of dis-
ruptions. In the adult model, two types of interaction can
be distinguished: direct and indirect. With direct interac-
tion, we mean that processes are dependent on input re-
ceived from other processes. Degraded input from one
220 Folia Phoniatr Logop 2019;71:216–227
DOI: 10.1159/000499426
specific impaired process can lead to problems at the sub-
sequent processing level (which may itself be intact). For
example, difficulties in phonological encoding may affect
speech motor control processes and thus cause (sensori)
motor symptoms [e.g., 49]. Indirect interaction refers to
adaptive and compensatory mechanisms. If some part of
the system suffers an impairment, the system will try to
adapt to the deviant circumstances and/or compensate
for the impediments. One simple way in which the system
can adapt is by slowing down the speech rate. A slow
speech rate is a general characteristic of MSD irrespective
of the underlying deficit. In many cases, it does not con-
stitute a primary symptom but rather acts as a compensa-
tory mechanism to make the control task easier [17, 59].
A clear example of adaptation and compensation mecha-
nisms on a functional-cognitive level can be seen in peo-
ple with anatomical deformities of the articulatory or-
gans, such as glossectomy [60–65] or dental occlusions
and prostheses [66–69].
In the case of an impairment in one of the processes or
representations in children, the interaction between the
different parts of the system gets an extra dimension. A
specific underlying impairment on one level or domain
also affects the development on adjacent levels or domains
[14, 36, 70–72]. Due to this developmental interaction,
the potential influence of primary deficits on adjacent
processing levels and of adaptive and compensatory
mechanisms is even stronger. A primary impairment at
the acoustic-perceptual level can, for example, cause the
phonological representations to be incorrect or under-
specified. This could in turn lead to a deviant and incom-
plete phonological system, primarily because it had to
learn from degraded input. Similar observations have
been described in children with a cleft palate, who often
develop specific articulation patterns to compensate for
their deficit [73–75]. These compensatory articulation
patterns may persist after the cleft has been surgically re-
paired, causing problems in the development of the chil-
dren’s phonological system [e.g., 73, 74, 76]. Another ex-
ample is the correlational evidence that suggests that poor
motor control in CAS is associated with poor develop-
ment of the lexicon, the phonological system, and audi-
tory processing [77, 78].
As a result of these interdependencies between the dif-
ferent levels of speech development and different parts of
the speech production chain, overlap of symptoms in
paediatric speech sound disorder is the rule rather than
the exception, which has frustrated attempts to find single
diagnostic markers for differential diagnosis. This inter-
dependent nature of the developing speech processing
Terband/Maassen/Maas
system means that the idea of finding single diagnostic
markers is fundamentally problematic and that attempts
to do so are unlikely to be fruitful. As Bishop [55] argued
in the context of specific language impairment already
more than 20 years ago, the neuropsychological principle
of double dissociation in the study of acquired disorders
in adults does not apply to developmental disorders. De-
velopmental disorders are characterised by associations
between functions rather than dissociation. Differential
diagnosis and treatment planning therefore require a dif-
ferent approach than classification based on overt speech
symptoms only. Along this line, Maassen [25] presented
a multi-level, multi-factorial description of the underly-
ing deficit of CAS.
Process-Oriented Diagnosis and Treatment Planning
The multi-factorial nature of developmental disorders
means that effective diagnosis and treatment planning re-
quire a dynamic, process-oriented approach aimed at de-
scribing the development of underlying processing defi-
cits to characterise disorders [31, 32, 36]. Based on the
integrated model of speech processing presented above
(Fig. 1), we propose a framework for process-oriented di-
agnosis and treatment planning of DSD (Table 1). Two
essential elements of our framework are that it comprises
general diagnostic categories within which specific treat-
ment goals/targets are formulated at the level of process-
es and representations.
General Diagnostic Categories
The framework that we propose distinguishes two
general diagnostic categories labelled developmental de-
lay and developmental disorder. The division between
these categories is based on fundamental differences in
the general characterisation of delayed versus deviant
speech development [79–82]. These differences are infor-
mative for both the treatment goals/targets and the choice
of the treatment method (the design of the treatment pro-
gramme; the choice and planning of exercises and activi-
ties). In the case of developmental delay, development
follows the typical pattern, but is delayed. The speech dif-
ficulties that the child experiences are not unusual and are
also commonly experienced by children with typical de-
velopment, but they are unusual for the age. Develop-
ment can also be delayed in the case of developmental
disorder; however, essential for the latter category is that
development does not follow the typical pattern. Speech
difficulties occur that are not usual during any stage in
Process-Oriented Diagnosis of DSD
typical development. The different characteristics of the
developmental trajectories demand a fundamentally dif-
ferent approach in terms of treatment and thus impor-
tantly serve to direct the choice of the treatment goals/
targets and methods.
Treatment Goals/Targets at the Level of Processes and
Representations
The goal of the speech acquisition process is to form
the different components of the speech production
chain as they exist and function in the adult system
(Fig. 1). What we propose with the current framework
is that when problems are encountered during speech
acquisition, the goals/targets for treatment are defined
in terms of these same components. In other words, the
possible treatment goals/targets correspond to the pro-
cesses and rules/representations that are presented in
the speech production model in Figure 1. Leaving the
language processes aside, the framework differentiates
four processing processes and three monitoring pro-
cesses. The framework further contains a set of phono-
logical rules and two representations that are used by the
different processes. A short overview of the different
components of the framework that form the possi-
ble  goals/targets for treatment is presented in Table 1
[83–114].
Hypothesis Testing
In this framework, a diagnosis comprises the assess-
ment of the two aspects described in the previous para-
graphs: (1) the developmental trajectory as a whole, char-
acterised by the developmental profile of processes, and
(2) deducing the underlying processing deficit(s) and,
from there, identifying treatment targets. Identifying the
developmental profile reveals whether specific processes
lag behind, which forms the basis for specifying treatment
targets. A delayed but balanced profile indicates develop-
mental delay, whereas an unbalanced profile indicates a
deviant development [82]. In addition, it needs to be de-
termined whether specific deficits underlie the unbal-
anced profile, which is especially important for the choice
of treatment method.
Thus, development could be delayed or deviant in dif-
ferent ways. Processes and rules/representations can be
less accurate, less automated, or slower. Additionally,
speech development could start typically until the onset
of the speech difficulties, for example, due to increased
demands. The assessment and characterisation of the de-
velopmental trajectory require standardised and norm-
referenced speech tasks, as well as language and oral mo-
Folia Phoniatr Logop 2019;71:216–227 221
DOI: 10.1159/000499426
Table 1. The processes and rules/representations of the speech production chain that form the possible treatment goals/targets, accom-
panied by examples of assessments and possible specific task comparisons based on these assessments that address these (note that these
are not exhaustive)

Process Rules/ Description Example assessment Example task comparisons

representations methods

Processing
Phonological Phonological Selection and sequencing of Word and non-word Word vs. non-word imitation (e.g.,
encoding representations linguistic/symbolic units that imitation: phoneme a higher segmental error rate in
[e.g., 39–41, 49–51] form goals for speech sounds: inventory and error words indicates poor representation
formation of a phonological analysis [e.g., 83–86] of lexeme)
Phonotactic phrase Word vs. non-word imitation (e.g.,
rules a higher segmental error rate in
non-words indicates either poor
auditory/memory functions or
poor output assembly)
Metrical Word vs. non-word imitation (e.g.,
spell-out a higher rate of stress attern errors
in non-words indicates either poor
auditory/memory functions or poor
output assembly)
Motor planning Phonemic Selection of articulatory Sentence, word, and More vs. less complex movements
[e.g., 40–42, 48, 50] mappings movement goals non-word imitation: and context (e.g., higher segmental
error analysis and error and deletion rates in more
coarticulation complex movement sequences;
[e.g., 87–90] lack of differentiation in anticipatory
coarticulation between consonant
contexts)
Motor Systemic Implementation in Sentence, word, and More vs. less complex movements
programming mapping muscle-specific motor non-word imitation: and context (e.g., higher
[e.g., 40, 43, 45, programmes consistency of repeated inconsistency in longer utterances
48, 50, 53] productions [e.g., and more complex
91–94] Adaptation to movement sequences [e.g.,
external circumstances consonant clusters])
(biteblock [95, 96]; lip
tube [97])
Motor execution Transmission of neural signals Diadochokinesis: More vs. less complex movements
[e.g., 40, 43, 45, to peripheral systems and maximum repetition (e.g., /tata/ vs. /sasa/; difficulties in
48, 50, 53] transformation into rate, rate variability, sensorimotor tuning cause higher
coordinated muscle activity phonation variability in /sasa/)
duration [e.g., 98–103]
Monitoring
Internal Phonemic Detection of incorrectly Word and non-word Early vs. late/no word uniqueness
self-monitoring mappings planned sounds or movements imitation: error point; high vs. low lexical
[e.g., 39, 51, 54] repair [e.g., 104, 105] neighbourhood density; elayed vs.
Delayed auditory normal auditory eedback (e.g.,
feedback absence of uniqueness point or
[e.g., 106, 107] neighbourhood density effects on
error repairs indicates poor preverbal
monitoring)
External Systemic Ad hoc adaptation of Auditory feedback Masking vs. no masking (e.g.,
self-monitoring – mapping articulation and error masking and reduced vowel contrast in masking
auditory [e.g., 40, and phonemic correction perturbation indicates poor phonemic mappings)
43–45, 50, 53] mappings [108–112]
External Systemic Information about the actual Somatosensory Masking vs. no-masking
self-monitoring – mapping state of the articulatory feedback masking and e.g., increased variability in masking
somatosensory system, ad hoc adaptation of perturbation [113, 114] indicates poor phonemic mappings)
[e.g., 40, 43–45, 50, 53] articulation and
error correction

222 Folia Phoniatr Logop 2019;71:216–227 Terband/Maassen/Maas

DOI: 10.1159/000499426
tor tasks [115, see also 116].1 To a large extent, these in-
struments are available (albeit not for all languages).
Identifying the processes involved requires an experi-
mental research methodology that has become available
only recently, and still needs to be further developed and
refined and subsequently implemented in clinical instru-
ments. In essence, the approach follows the principal
ideas of Stackhouse and Wells [12, 121], later advocated
by Baker et al. [38], and is very similar in spirit to the Psy-
cholinguistic Assessments of Language Processing in
Aphasia (PALPA) [122]. The approach comprises a reit-
erative process of hypothesis testing by means of objec-
tive measurements of speech output in systematically var-
ied tasks under systematically varied conditions. Differ-
ent speaking tasks and speaking conditions put different
demands on different components of the speech produc-
tion model (Table 1). In the right combination, this en-
ables a demonstration of the processes involved. Based on
a specific test result, a hypothesis about the speech im-
pairment is formulated or adjusted, which is then evalu-
ated by means of a subsequent test or condition. Eventu-
ally, after a number of steps, this leads to a profile charac-
terising which processes and rules/representations of the
speech production chain are involved. Ultimately, a spe-
cific diagnosis is established by deducing the underlying
deficit(s) based on this profile, in combination with the
characterisation of the impairment. A concrete treatment
plan can then be drafted to target (or circumvent) the im-
pairment, taking into account other relevant aspects such
as age, severity, and individual characteristics and per-
sonal interests.
First steps in such profiling of speech production and
perception characteristics based on an extensive assess-
ment battery have been successfully made in research ap-
plications for diagnostic group assignment for some time
[123–125]. Similarly, model-based approaches compris-
ing detailed comparisons of different tasks and/or condi-
tions to specify the underlying speech processing difficul-
ties involved in children with speech impairment are be-
1 Although there is debate about the potential utility of non-speech oral mo-
tor tasks [98, 99, 116–120], they represent an important first step in differ-
ential diagnosis investigating the anatomy and (neuromuscular) functional-
ity of the oral motor system. The necessity of non-speech oral motor tasks
directly follows from classic definitions of DSD. CAS, for example, is defined
as “a neurological childhood (pediatric) speech sound disorder in which the
precision and consistency of movements underlying speech are impaired
in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal
tone)” [37, p. 3; emphasis added]. A non-speech oral motor examination
offers insight into possible neuromuscular or structural anatomical impair-
ments. Furthermore, Thoonen et al. [98, 99] have shown that diadochokine-
sis tasks are discriminative between CAS and DD.
Process-Oriented Diagnosis of DSD
ing used successfully in experimental studies [108, 110,
126, 127]. A particularly nice example is the recent study
by Geronikou and Rees [127], who used a battery of
speech production and perception tasks to specify – for
each child individually – the underlying speech process-
ing difficulties in four 4.5- to 5.5-year-old children with a
PD with very similar speech error patterns. The speech
output tasks included picture naming, word repetition,
and non-word repetition, while the perception tasks in-
cluded non-word discrimination and mispronunciation
detection. All children showed similar problems in the
speech production tasks, but the results showed specific
differences in the performance on the perception tasks for
these specific target sounds. Two of the children had dif-
ficulties in the mispronunciation detection task but not
in non-word discrimination, leading the authors to infer
that for these children the problem resided in the phono-
logical representations of the target sounds. The other 2
children had no difficulty with either mispronunciation
detection or non-word discrimination, suggesting that
the target sounds were well specified in the phonological
representations but not in the motor representations
(phonemic mappings in the terminology of the present
paper). As the authors concluded, this makes a funda-
mental difference for intervention [127].
The example above, as well as the PALPA [122], can be
characterised as a neuropsychological approach, com-
prising the administration of a test battery and deducing
from the profile which underlying process(es) is/are dis-
rupted. Such a comprehensive speech profile is the first
step towards a process-oriented diagnosis in which un-
derlying deficits are identified. The next step is to direct-
ly manipulate speech processes, for instance, by speeding
up, masking noise, auditory perturbation, distorting kin-
aesthetic feedback, or short learning tasks (brief diagnos-
tic therapies). Rather than having to interpret a particular
speech profile, which relies on a matched comparison
group, in these varying conditions the subject is his or her
own control. The required experimental methods are
available and are being further developed and fine-tuned
in research studies. Slowly but certainly, they are becom-
ing available for use in clinical practice.
Conclusions
In this paper, we presented a model of speech process-
ing that can serve as a framework for a process-oriented
approach to diagnosis and treatment planning of DSD.
This process-oriented approach holds important advan-
Folia Phoniatr Logop 2019;71:216–227 223
DOI: 10.1159/000499426
tages, in that it offers direct leads for treatment aimed at
the specific underlying impairment and adjusted during
the course of the speech disorder. Although the diagnos-
tic procedure will be more time-consuming than the cur-
rent procedures, a more targeted treatment tailored to the
specific needs of the individual promises to be more ef-
fective and efficient. Moreover, we believe that current
and future technological advances in diagnostic instru-
mentation, such as automated test administration and
automated processing and analyses of test performance,
will partly eliminate these drawbacks.
Possibly more problematic is that this process-orient-
ed approach requires a different way of thinking by clini-
cal practitioners [12, 33, 34, 38, 40, 50, 121]. Speech ther-
apists are generally trained to focus on speech output
skills, to think and work according to a framework of di-
agnostic classification based on behavioural symptoms
only and plan treatment according to the corresponding
protocol. A change to a practice of hypothesis testing in a
psycholinguistic framework requires a different educa-
tion and training to provide speech therapists with the
theoretical background and the clinical skills to utilise
and interpret a process-oriented instrument for diagnos-
tics and treatment planning [31–33]. The step from a be-
havioural to a process-oriented diagnostic and treatment
planning means, in the words of Baker et al. [38], “refram-
ing the ways in which we understand children’s commu-
nication problems” (p. 700) [see also 33, 34, 40, 50, 121].
Acknowledgements
This work was supported by the Netherlands Organization for
Scientific Research (NWO-VENI grant 275-89-016 awarded to
H.T.), and the National Institutes of Health (National Institute of
Deafness and Other Communication Disorders grant K01-
DC010216 awarded to E.M.).
Statement of Ethics
The authors have no ethical conflicts to disclose.
Disclosure Statement
The authors have no conflicts of interest to disclose.

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